The effort to expand Medicaid in Kansas fell apart Monday as the House failed to override Gov. Sam Brownback’s veto of a bill that would have expanded the health care program to thousands of low-income people in the state.

The 81-44 vote, three shy of the 84 needed to overcome the governor’s opposition, effectively ends the Medicaid expansion push in Kansas after it successfully passed both chambers with bipartisan support earlier this year.

That was then. This is now. Kansas now has a Democratic governor who supports Medicaid expansion, and yesterday this happened (via Jim McLean of the Kansas News Service):

The Centers for Medicare & Medicaid Services has approved a waiver request for work requirements in Ohio’s Medicaid program.

...CMS rolled out guidance on these waivers in January 2018, and since then eight states, including Ohio, have had requests approved. Several additional states have submitted waivers that the agency has yet to weigh in on.

...Arkansas is the only state where such work requirements have formally been launched, and in the last several months of 2018, more than 18,000 people lost Medicaid coverage as a result of the work requirement. The Kaiser Family Foundation estimated that most of these losses were a result of the administrative requirements associated with reporting work hours.

Access Health CT, Connecticut's state-based ACA exchange, released their 2019 Open Enrollment Period report, and it's one of the most extensively detailed & granual looks at the year's enrollment data. They've included the normal stuff, of course (subsidized vs. unsubsidized, metal levels, age and income brackets, etc)...but they've also done a very deep dive into data points I haven't seen before by cross-indexing categories.

For instance, not only did they break out "enrollment attrition reasons" (that is, why 2018 enrollees who didn't renew their policies chose not to), but they actually broke that out into what those enrollees' financial assistance status was.

The level of detail here is pretty impressive and somewhat overwhelming (there's 25 pages of charts & graphs), but if you're a healthcare nerd interested in what's going on in the Nutmeg State, knock yourself out!

DENVER – Coloradans who get financial help buying health insurance through Connect for Health Colorado® are paying an average 14 percent less in “net premium” – what they pay after assistance – compared to the average net premium in 2018, according to data released today.

Three of every four current Connect for Health Colorado customers qualify for financial help to reduce the monthly cost of health insurance. The average net premium for those Coloradans is $117 per month, down from $136 per month last year.

“We are happy that we are able to make health insurance affordable for so many people,” said Kevin Patterson, Chief Executive Office of Connect for Health Colorado. “The number of our customers receiving help rose this year by seven percentage points, to 76 percent, an important increase. We know we have more work to do, and are committed to expanding our impact as we work with policy makers, our stakeholders and our customers throughout the state.

In light of the flurry of state-level legislation locking in ACA protections in New Mexico and Maine over the past few weeks, this seems like a good point to check in on other states as well.

One more time: Here's what the ACA's "3-Legged Stool" looks like as of March 2019. The Trump Administration and Congressional Republicans tried to sabotage the Green Leg by cutting off Cost Sharing Reduction reimbursement payments...but the insurance carriers mostly cancelled this out by Silver Loading. The end result of this is that the federal government is actually shelling out up to $20 billion more in APTC subsidies per year, more than cancelling out the $10 billion or so they're saving in unpaid CSR costs (and they may still have to pay that as well anyway!)

Last week I noted that New Mexico had capped off a flurry of positive healthcare policy legislation by passing a bill (in dramatic fashion) which would lock in ACA-level protections for those with pre-existing conditions in the event the ACA itself is ever repealed or weakened.

Once this bill is signed by the Governor (which is almost certain to happen), New Mexico will join four other states (Massachusetts, New York, Colorado and Virginia) in fully protecting all three types of "blue leg" protections: Guaranteed Issue, Community Rating and Essential Health Benefits. The New Mexico bill also locks in a fourth ACA protection: The prohibition on annual or lifetime coverage limits.

The CSR Lawsuit Saga has been a continuous rollercoaster ride since 2014 at this point, with the original lawsuit (brought by John friggin' Boehner) seeing twists including one of the plaintiffs becoming one of the named defendents, and the named defendent changing at least three times as the Trump Administration went through several HHS Secretaries over the course of a few months.

NOT hurting the very people he was trying to hurt (low-income enrollees);

HURTING the very people he supposedly wasn't trying to hurt (middle-income enrollees), and as an added bonus...

INCREASING federal spending by a projected $20 billion dollars per year in increased premium subsidies

Nearly 100 insurance carriers who were stiffed by Trump out of a couple billion dollars owed to them for 2017 sued the federal government, and the judges in the cases ruled in their favor, ordering the feds to pay up. This much was completely expected and not at all out of the ordinary.

When it comes to discussing changes in healthcare policy, one of the most important--and most frustrating--topics which have to be tackled is how much healthcare services actually cost. I'm not necessarily talking about how much the patient pays, although that's obviously important as well...I'm referring to how much the healthcare providers charge and get paid.

Doctors, hospitals, clinics, pharmaceutical companies, medical device makers and so forth all get paid different amounts for different services from different payors, depending on whether it's a private insurance carrier, Medicare or Medicaid...and those rates generally range widely from state to state and carrier to carrier. One partial exception to this is Maryland, where they've been experimenting fairly successfully with a concept called "all-payer" rate setting:

*("major" is obviously a subjective term depending on who's using it.)

Until this weekend, "Medicare for All or Bust" seemed to be the most critical litmus test for any major 2020 Democratic Presidential candidate. No fewer than sixteen Democratic Senators co-sponsored Bernie Sanders' S.1804 "Medicare for All" single payer bill in September 2017, including five of the six U.S. Senators currently running for the 2020 nomination: Sanders himself, Cory Booker, Kirsten Gillibrand, Kamala Harris and Elizabeth Warren (the only Senator running who didn't cosponsor the bill was Amy Klobuchar.)

Recently, however, there have been a few interesting developments along the "Where do the Dem candidates stand on healthcare policy" front:

In the 5 1/2 years that I've been operating this website (has it really been that long?), I was surprised (pun intended) to realize that out of the 5,600+ blog entries that I've posted, only 2-3 have mentioned "Surprise Bills" (also known as "Balance Billing", although I think there are some differences between the two):

The state Senate gave initial approval Wednesday to a Senate bill that would allow small-business employers to offer an association health-insurance plan, or AHP, that could provide lower premium costs.

Senate Bill 86 received a 40-8 vote on second reading, but an objection to a third reading kept it on the Senate calendar until at least today.

The GOP holds a majority in the NC Senate, but only by 29 to 21, so stopping this there was apparently a lost cause. They also hold a 65 to 54 majority in the state House. I'm not sure whether SB 86 has already been voted on there or not. If it passes both, it would be up to Democratic Governor Roy Cooper to veto the bill.

Over the past year or so, ever since Donald Trump issued an executive order re-opening the floodgates on non-ACA compliant "short-term, limited duration" (STLD) healthcare policies (otherwise known as "junk plans" since they tend to have massive holes in coverage and leave enrollees exposed to financial ruin in many cases), numerous states have passed laws locking in restrictions on them or, in a few cases, eliminating them altogether:

Arthur Childs, DO, FACOI is an internist specializing in critical care medicine in Cape May Court House*, New Jersey. About a year ago, as part of a project for the Jefferson School of Population Health, he put together his own Strategic Roadmap for Healthcare Delivery in the United States as a potential alternative to the various universal coverage proposals being tossed around on the left side of the aisle these days. He asked me to read it over and wanted my feedback.

I've done so, and while I'm still a strong proponent of going the Medicare for America route, he makes a lot of useful points and provides much food for thought. It's also very well-researched and cited, and I felt it deserved a wider audience. And so, with the permission of both him and the Jefferson School of Population Health, I'm presenting his full paper with a few of my own thoughts interspersed.

(sigh) Well, it was a good run while it lasted. As I noted last week, New Mexico's new Democratic trifecta government has been on something of a tear in the first few months of 2019, either passing or advancing a number of positive healthcare policies, including:

In addition, there was one more important piece of legislation which looked like it was going to go through without too much fuss: HB 436, which would simply lock in protections for New Mexico residents with pre-existing conditions at the same level that the Affordable Care Act already does nationally:

Governor Baker announced today that the Massachusetts Health Connector completed Open Enrollment with the highest membership in the 13-year history of the state’s health insurance exchange, covering 282,000 people with health insurance.

Heh. "13-year history" took a moment to register...but of course Massachusetts has had a health insurance exchange website since 2006, when "RomneyCare" went into effect.

ALBANY, N.Y. (March 12, 2019) - NY State of Health, the state’s official health plan Marketplace today released 2019 health plan enrollment by insurer. Twelve insurers offer Qualified Health Plans (QHP) and sixteen insurers offer the Essential Plan (EP) statewide in 2019. Most consumers have a choice of at least four QHP and EP insurers in every county of the state.

“We are pleased to once again offer consumers a broad choice of high-quality, affordable health plan options in every county of the state,” said NY State of Health Executive Director, Donna Frescatore. “And the wide distribution of enrollment across insurers shows us that consumers value this choice.”

No, it won't go anywhere with the House held by Democrats, but even so:

President Trump is releasing a $4.7 trillion budget plan Monday that stands as a sharp challenge to Congress and the Democrats trying to unseat him, the first act in a multi-front struggle that could consume Washington for the next 18 months.

The budget proposal dramatically raises the possibility of another government shutdown in October, and Trump used to the budget to notify Congress he is seeking an additional $8.6 billion to build sections of a wall along the U. S.-Mexico border.

Here we go again...

Trump’s “Budget for a Better America” also includes dozens of spending cuts and policy overhauls that frame the early stages of the debate for the 2020 election. For example, Trump for the first time calls for cutting $845 billion from Medicare, the popular health care program for the elderly that in the past he had largely said he would protect.

OK, I'm not sure how this one slipped by me...over the past year, a half-dozen states having 1332 Waiver Reinsurance programs approved by CMS (among the few modifications of default ACA provisions approved by the Trump Administration that I agree with).

The states approved have included red ones like Wisconsin and Alaska...but also blue ones like Maryland and New Jersey. For whatever reason, CMS Administrator Seema Verma, while doing all she can to sabotage the ACA in other ways, seems to have a soft spot in her heart for reinsurance, which I'm not going to complain about.

In any event, along with the states which have already had their reinsurance waivers approved, there are several other states where reinsurance proposals have been proposed by either state legislators or governors, including the newly-elected governors of Michigan (Gretchen Whitmer) and Connecticut (Ned Lamont) respectively.

Minnesota's ACA exchange, MNsure, is among the better ones when it comes to data transparency. Here's some key data from their monthly board meeting on March 6th.

A couple of other interesting items of note:

It looks like MNsure's annual budget averages around $36 - $40 million per year, with between 50-60% of it coming from their 3.5% premium fee on exchange-based enrollments (I would think they'd spread the fee across off-exchange enrollments as well, as some other state exchanges do, for consistency's sake, which would reduce the amount of additional funding they need from the state Dept. of Human Services, but that's up to the state legislature, I presume).

New Analysis Finds Leading State-Based Marketplaces Have Performed Well, and Highlights the Impact of the Federal Mandate Penalty Removal

The report examines the impact that federal and state actions have had on state-based marketplaces and the federally facilitated marketplace (FFM).

Cumulative premium increases in California, Massachusetts and Washington are less than half of the increases seen in FFM states, but 2019 premium increases spiked in California and Washington compared to Massachusetts, which continued its state-based penalty.

WASHINGTON D.C. — A new report highlights the benefits of state-based exchanges, particularly in the areas of controlling premium costs and attracting new enrollment. The report, which was produced by Covered California, the Massachusetts Health Connector and the Washington Health Benefit Exchange, found that premiums in these states were less than half of what consumers saw in the 39 states that relied on the federally facilitated marketplace (FFM) between 2014 and 2019.

Connecticut lawmakers are joining other states that have unveiled proposals to expand government-run health coverage, with plans to extend state health benefits to small businesses and nonprofits, and to explore a public option for individuals.

Under two measures announced Thursday, officials would open the state health plan to nonprofits and small companies – those with 50 or fewer employees – and form an advisory council to guide the development of a public option. The legislation would allow the state to create a program, dubbed “ConnectHealth,” that offers low-cost coverage to people who don’t have employer-sponsored insurance.

HB 436 passed on the House floor by a vote of 40-24 on Thursday afternoon. The bill would bring New Mexico's state law dealing with pre-existing conditions into line with federal law.

Rep. Liz Thomson, the bill's sponsor, says health insurance coverage for people with pre-existing conditions is already protected under the federal Affordable Care Act. She wants New Mexico's state law to do the same.

"Because before the Affordable Care Act came along, insurance companies could discriminate based on gender, they charge women more, and on pre-existing conditions," Thomson said.

Last year, Republican Governor of Kentucky Matt Bevin, who had campaigned heavily on a promise to repeal ACA Medicaid expansion altogether, partly changed his tune once he actually took office. Instead of kicking all 450,000 low-income Kentucky residents off the program completely, he first imposed an absurdly insulting and cumbersome "frequent flyer"-style program:

Kentucky is moving closer to an overhaul of the state's Medicaid program Bevin has said is aimed at controlling costs and encouraging more personal responsibility in consumers, changes that include elimination of basic dental and vision benefits for most "able-bodied" adults who instead would have to earn them through a "rewards" program.

..."It is expensive to go to a dentist," he said. "These changes are just ludicrous."

The Centers for Medicare & Medicaid Services (CMS) issued a request for information (RFI) today that solicits recommendations on how to eliminate regulatory, operational and financial barriers to enhance issuers’ ability to sell health insurance coverage across state lines. This announcement builds on President Trump’s October 12, 2017 Executive Order, “Promoting Healthcare Choice and Competition Across the United States,” which intends to provide Americans relief from rising premiums by increasing consumer choice and competition.

I've attended Netroots Nation twice before. The first time was way back in 2007 in Chicago, back when it was actually called Yearly Kos (the conference started out as an offshoot of the Daily Kos progressive online community). They changed the name to "Netroots Nation" the following year to reflect that it had grown larger than any single website. The second time was here in Detroit in 2014, which happened to also be the same point I was at my peak media awareness (my "fifteen minutes of fame" so to speak).

For more than a decade, Netroots Nation has hosted the largest annual conference for progressives, drawing nearly 3,000 attendees from around the country and beyond. Netroots Nation 2019 is set for July 11-13 in Philadelphia.

The general thinking at the time was that the judges would simply rule in the carriers favor and order the Trump Administration to pay the carriers the money owed to them from the last three months of 2017 (over $2 billion nationally, although the amounts at stake for each individual carrier suing is generally kmore along the lines of seven figures each). If this had been what happened there likely wouldn't have been much more to the story.

Instead, all three judges ruled--on behalf of dozens of carriers, since at least one of the cases is a class action suit--that the government owes them CSR payments for not only Q4 2017, but all twelve months of 2018 as well, assuming the carriers wanted to demand those payments.

Regular readers know that I've been calling for Congress to #KillTheCliff for years:

Once again: Under the ACA, if you earn between 100-400% FPL (between $12,140 and $48,560 for a single person), you're eligible for APTC assistance on a sliding scale. The formula is based on the premium for the Silver "benchmark" plan available in your area, which averages around $611/month in 2019.

Here's how the formula works under the current ACA wording:

...Here's the problem: If they earn exactly 400% FPL ($48,560), they'll also only have to pay 9.86% ($4,802), receiving $2,530 in subsidies for the year....

I don't know what the status is of H.R. 5155 (the House Democrats catch-all "ACA 2.0" bill which I've been pushing for awhile now), but it looks like individual elements of it are also in the works as standalone bills:

The Health Subcommittee with hold a legislative hearing on Wednesday, March 6, at 10 am in the John D. Dingell Room, 2123 Rayburn House Office Building. The hearing is entitled, “Strengthening Our Health Care System: Legislation to Lower Consumer Costs and Expand Access.” The bills to be the subject of the legislative hearing are as follows.

Younger adults pay a lower percentage of their income (at a given level) for the benchmark plan

Older adults are held harmless

All individuals, regardless of income, are eligible for subsidy assistance

CSRs appropriated

CSRs expanded

Full advertising and outreach funded

Health insurance premium tax suspended

...It looks like the insurers are trying to lay markers for where they want to see things in 2021 or 2022. They are looking at a fix and expansion of the current paradigm instead of a complete replacement of the system.

A big shout-out to Josh Dorner for providing a roundup of the current status of a five different lawsuits (six, really, although two of them are on the same topic in two different states) fighting back against GOP/Trump Administration sabotage of the Affordable Care Act, including:

There's also the various CSR reimbursement payment lawsuits filed by various insurance carriers. Those should have been a fairly minor issue only relating to about $2 billion in payments dating back to the 4th quarter of 2017...but as I explained in detail here, these suits may instead turn into an even more massive headache for the Trump Administration, and rightly so.

Amidst all the depressing news about various GOP states moving backwards on healthcare policy by gunking up Medicaid programs to add draconian work requirements, lowering the eligibility thresholds, stripping benefits and so forth, there were two positive developments in deep red territory last week, both relating to Medicaid work requirements:

A bill that sought to place work or other requirements on Medicaid recipients in West Virginia has died in the House of Delegates.

A House committee put the bill on its inactive calendar Wednesday, Feb. 27, the final day that legislation could be passed in their chamber of origin. The full House earlier Wednesday debated the bill but stopped short of voting on it, and did not take up the bill during a late evening session before adjourning.

The bill would have required able-bodied adults to work, participate in workforce training or community service, or attend a drug treatment or recovery program for at least 20 hours per week.

UPDATE: Please see Esther F's comment below this post for some important caveats/points regarding survey bias.

I had to think long and hard about what headline to use for this blog post. The first ones which came to mind were pretty crude, along the lines of "I've got mine, f*ck you!". After giving it some thought, I went with something a bit more genteel.

eHealth is one of the largest private online insurance brokers in the country. They sell ACA-compliant healthcare policies, but also sell other types of coverage, including non-ACA "short-term" plans, which regular readers (as well as eHealth) are aware I am not a fan of, to put it mildly.

Regardless, while I may not care for some of their offerings, they seem to be a reasonable company overall, and they regularly provide handy customer surveys on various ACA/healthcare topics which I find useful from time to time.